Combined David and Frozen Elephant Trunk Procedure in Acute Aortic Dissection
11 March 2018
12 June 2018
30 July 2018 (online)
Background Valve sparing aortic root repair by reimplantation (David procedure) is an established technique in acute aortic dissection Stanford type A involving the aortic root. In DeBakey type I dissection, aortic arch replacement using the frozen elephant trunk (FET) was introduced to promote aortic remodeling of the downstream aorta. The combination of these two complex procedures represents a challenging surgical strategy and was considered too risky so far.
Methods All patients with acute aortic dissection DeBakey type I undergoing valve sparing aortic root repair by reimplantation technique of David combined with extended aortic repair using the FET at our center between October 2009 and December 2016 were evaluated. Outcomes are compared with patients who underwent prosthetic aortic root replacement and FET for aortic dissection in the same timeframe.
Results A total of 28 patients received combined David and FET procedure, while 20 patients received prosthetic aortic root replacement and FET procedure. Thirty-day mortality was 10.7% (n = 3) for the David group and 20% (n = 4) for the root replacement group (p = 0.43). Postoperative echocardiographic control revealed an excellent aortic valve function with regurgitation grade 0° or maximum grade I° and a mean gradient of 4.3 ± 2.1 mm Hg in all patients in the David group versus 7.2 ± 2.4 mm Hg in the aortic root replacement group, p = 0.003. Computed tomography angiography scan showed positive aortic remodeling in all but three patients (91.9%). Mid-term follow-up survival was 82.1% in the David group and 68.4% in the root replacement group, p = 0.28. There was no need for reintervention at the root or descending aorta.
Conclusion Simultaneous application of the David and FET procedure in patients with acute aortic dissection is safe and feasible in experienced hands as compared with standard aortic root replacement plus FET. The mid-term outcomes are encouraging and noninferior to conventional surgery results.
The manuscript was presented at the 31st EACTS Annual Meeting, held in Vienna, Austria, October 2017.
- 1 Erbel R, Aboyans V, Boileau C. , et al; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873-2926
- 2 David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg 2017; 153: 232-238
- 3 Beckmann E, Martens A, Pertz J. , et al. Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients. Eur J Cardiothorac Surg 2017; 52: 319-324
- 4 Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection. Ann Thorac Surg 2012; 94: 1230-1234
- 5 Roselli EE, Loor G, He J. , et al. Distal aortic interventions after repair of ascending dissection: the argument for a more aggressive approach. J Thorac Cardiovasc Surg 2015; 149: 117-24.e3
- 6 Evangelista A, Salas A, Ribera A. , et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation 2012; 125: 3133-3141
- 7 Fattouch K, Sampognaro R, Navarra E. Long-term results after repair of type A acute aortic dissection according to false lumen patency. Ann Thorac Surg 2009; 88: 1244-1250
- 8 Shrestha M, Haverich A, Martens A. Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections. Eur J Cardiothorac Surg 2017; 51: i29-i34
- 9 Dohle DS, Tsagakis K, Janosi RA. , et al. Aortic remodelling in aortic dissection after frozen elephant trunk. Eur J Cardiothorac Surg 2016; 49: 111-117
- 10 Iafrancesco M, Goebel N, Mascaro J. , et al. International E-vita Open Registry Group. Aortic diameter remodelling after the frozen elephant trunk technique in aortic dissection: results from an international multicentre registry. Eur J Cardiothorac Surg 2017; 52: 310-318
- 11 Jakob H, Dohle D, Benedik J. , et al. Long-term experience with the E-vita Open hybrid graft in complex thoracic aortic disease. Eur J Cardiothorac Surg 2017; 51: 329-338
- 12 Katayama A, Uchida N, Katayama K, Arakawa M, Sueda T. The frozen elephant trunk technique for acute type A aortic dissection: results from 15 years of experience. Eur J Cardiothorac Surg 2015; 47: 355-360 , discussion 360
- 13 Di Eusanio M, Castrovinci S, Tian DH. , et al. Antegrade stenting of the descending thoracic aorta during DeBakey type 1 acute aortic dissection repair. Eur J Cardiothorac Surg 2014; 45: 967-975
- 14 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103: 617-621
- 15 Vahanian A, Alfieri O, Andreotti F. , et al; Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC). European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33: 2451-2496
- 16 Tsagakis K, Pacini D, Di Bartolomeo R. , et al. Multicenter early experience with extended aortic repair in acute aortic dissection: is simultaneous descending stent grafting justified?. J Thorac Cardiovasc Surg 2010; 140: 116-120
- 17 Ishimaru S. Endografting of the aortic arch. J Endovasc Ther 2004; 11: II62-II71
- 18 Chan V, Malas T, Lapierre H. , et al. Reoperation of left heart valve bioprostheses according to age at implantation. Circulation 2011; 124: 75-80
- 19 Stassano P, Di Tommaso L, Monaco M. , et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009; 54: 1862-1868
- 20 Bourguignon T, El Khoury R, Candolfi P. , et al. Very long-term outcomes of the Carpentier-Edwards perimount aortic valve in patients aged 60 or younger. Ann Thorac Surg 2015; 100: 853-859
- 21 Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36: 1152-1158
- 22 Oxenham H, Bloomfield P, Wheatley DJ. , et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003; 89: 715-721
- 23 van Geldorp MW, Eric Jamieson WR, Kappetein AP. , et al. Patient outcome after aortic valve replacement with a mechanical or biological prosthesis: weighing lifetime anticoagulant-related event risk against reoperation risk. J Thorac Cardiovasc Surg 2009; 137: 881-886
- 24 Leontyev S, Borger MA. David operation for type A aortic dissection: risks and rewards. Eur J Cardiothorac Surg 2017; 52: 325-326